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As a reminder, injectable hyaluronate acid products to treat osteoarthritis
of the knee are no longer available through the AmeriHealth Direct Ship Drug
Program. This includes EuflexxaTM, Gel-One®,
Gel-SynTM, GenVisc 850®, Hyalgan®,
Hymovis®, Monovisc®, Orthovisc®,
Supartz®, Synvisc®, Synvisc-OneTM, and
VISCO-3TM, as well as any new hyaluronate acid product that receives
approval from the U.S. Food and Drug Administration (FDA).
These drugs will continue to be covered under the medical benefit for
members who meet the medical necessity criteria listed in the applicable
medical policy:
- Commercial: #11.14.07o: Intra-Articular Injection of Hyaluronan for
the Treatment of Osteoarthritis
- Medicare Advantage: #MA11.023c: Hyaluronan Acid Therapies for
Osteoarthritis of the Knee
To view these policies, visit our
Medical Policy Portal. Select
Accept and Go to Medical
Policy Online, and then select the
Commercial or
Medicare
Advantage tab from the top of the page, depending on the version of the
policy you would like to view. Then type the policy name or number in the
Search field.
How this change affects providers
Providers who prescribe hyaluronate acid products must purchase these drugs
from the manufacturer or a specialty pharmacy vendor and stock them in their
office. In order to receive reimbursement for the cost of the pharmaceutical,
the provider will need to submit a claim to AmeriHealth.
In January 2015, letters were sent to physicians who prescribe and
administer hyaluronate acid products to notify them of this change and to
provide more information about the process for purchasing these drugs.
Precertification requirements
Also in January 2015, precertification requirements were removed for
Orthovisc®, Synvisc®, and
Synvisc-OneTM, our three preferred products. All other drugs in this
class including, but not limited to, EuflexxaTM,
Gel-One®, Gel-SynTM, GenVisc 850®,
Hyalgan®, Hymovis®, Monovisc®,
Supartz®, and VISCO-3TM still require
precertification from AmeriHealth. Providers who administer nonpreferred
hyaluronate acid products without precertification approval will not be
reimbursed.
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